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FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
267
Service:
DCA
Call Sign:
WWLM-CD
Channel:
36 (UHF)
File Number:
0000027839
FRN:
0026907345
Date Submitted:
10/07/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

HC2 STATION GROUP INC.

RENEE ILHARDT

450 PARK AVENUE

29TH FLOOR

NEW YORK, NY 10022

United States

 +1 (954) 606-5486 RILHARDT@HC2BROADCASTING.COM Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 

Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

The Preparer is same as the reimbursement contact.

 

 

 

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan Retune existing antenna by installing a fine matcher per manufacturer requirement. Retune existing transmitter & exciter. Replace mask filter. Continue operations with existing equipment for the interim. Transition to new mask filter.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Ownership Owned
Owner N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer Rohde & Schwarz
Model NV8306
Year 2007
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.8 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 3 kW
Other Power N/A
New Exciter Is a new exciter needed? No

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Additional field engineering time

Additional field engineering time

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Retune Existing
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 8
Design power capacity in use 66.7 %
Lower Limit 470.00 MHz
Upper Limit 806.00 MHz
Other Antenna Type N/A
ERP: 15.0 kW
Manufacturer Alive
Model ATC-BPH8C2
Year 2014

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1026954
Coordinates (NAD83) Latitude (NAD83) 40° 11' 24.0" N-
Longitude (NAD83) 080° 13' 55.0" W-
Overall Structure Height 226.05 feet
Support Structure Height 226.05 feet
Ground Elevation Above Mean Sea Level (AMSL) 1267.70 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WASHINGTON BROADCASTING COMPANY
Date Constructed 01/01/1981


Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 350
Explanation The station's ownership group has multiple transmitter sites (14 TV) and operates with minimal staff. It does not have personnel available for any of these tasks, nor is the staff trained to provide any of these services.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Internal Employee Time Costs

Internal Employee Time Costs

Repacking Related Tax Services

Repacking Related Tax Services

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Information not provided.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $110,105.00 $22,912.76 N/A $11,467.76 N/A
Total for all systems $306,703.63 $107,451.63 N/A $58,368.15 N/A
Primary Transmitter NV8306 $110,105.00 $22,912.76 $11,467.76
Additional field engineering time $750.00 $750.00 N/A $750.00 N/A
3 kW mask filter $4,155.00 $10,717.76 See attached quote from ERI $10,717.76 N/A
UHF and VHF - minor banding issues $105,200.00 $11,445.00 N/A N/A N/A

Components

Actual Information Description File Name
Additional field engineering time

Component Description:
Technical services to change frequency and power. #19051
Amount:
$750.00
3 kW mask filter

Component Description:
Filter balance. #FILTERS-53874
Amount:
$5,597.76

Component Description:
Transmitter related cost. #FILTERS-500
Amount:
$5,120.00
UHF and VHF - minor banding issues Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $6,730.00 $6,400.00 N/A $0.00 N/A
Total for all systems $306,703.63 $107,451.63 N/A $58,368.15 N/A
Primary Antenna ATC-BPH8C2 $6,730.00 $6,400.00 $0.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $84,200.00 $2,500.00 N/A $0.00 N/A
Total for all systems $306,703.63 $107,451.63 N/A $58,368.15 N/A
Primary Tower TOWER $84,200.00 $2,500.00 $0.00
Short Tower (less than 500') $84,200.00 $2,500.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $89,028.63 $67,761.37 N/A $45,122.62 N/A
Total for all systems $306,703.63 $107,451.63 N/A $58,368.15 N/A
Outside Professional Services $89,028.63 $67,761.37 $45,122.62
Repacking Related Tax Services $120.74 $120.74 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $120.74 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $0.00 N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,500.00 The original estimate was only for the consulting engineer and did not include attorney's fees.
Project management of the transition $55,300.00 $35,992.74 N/A $35,992.74 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,250.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $1,361.25 N/A
Internal Employee Time Costs $2,897.89 $2,897.89 N/A $2,897.89 N/A

Components

Actual Information Description File Name
Repacking Related Tax Services

Component Description:
Services rendered in relation to discussion and analysis of the tax treatment of invoice related to FCC repacking. #1034466828-9
Amount:
$120.74
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Please refer to lines 3 and 4 of the attached invoice totaling $301. Less the 10% discount received the amount due is $270.90. Please note the hours and rates are provided at the bottom of the invoice.
Amount:
$270.90
Prepare request for Special Temporary Authorization Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form

Component Description:
Please see line 2 of the invoice - prepare and or review reimbursement form.
Amount:
$2,500.00

Component Description:
Please refer to lines 1,2,5 and 6 of the attached invoice totaling $645. Less the 10% discount received the amount due is $580.50. Please note the hours and rates are provided at the bottom of the invoice.
Amount:
$580.50
Project management of the transition

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #471659
Amount:
$1,206.00

Component Description:
Project management service. #19-243
Amount:
$287.50

Component Description:
Project management service. #19-328
Amount:
$450.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #472232
Amount:
$901.10

Component Description:
Project management service. #19-238
Amount:
$675.00

Component Description:
Project mangement service. #19-266
Amount:
$812.50

Component Description:
Legal services cost. #475049
Amount:
$298.00

Component Description:
Project management service. #19-283
Amount:
$487.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #1158
Amount:
$723.06

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #474784
Amount:
$374.23

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 27 stations. #130
Amount:
$450.81

Component Description:
Project management services. #19-182
Amount:
$1,212.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 27 stations. #115
Amount:
$467.12

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #1165
Amount:
$497.50

Component Description:
Project management service. #19-149
Amount:
$500.00

Component Description:
Project management service. #19-315
Amount:
$1,312.50

Component Description:
Project management service. #19-311
Amount:
$87.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #473451
Amount:
$1,054.24

Component Description:
Project management service. #19-267
Amount:
$875.00

Component Description:
Project management service. #19-277
Amount:
$337.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #1150
Amount:
$630.93

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #1163
Amount:
$607.03

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #475948
Amount:
$419.80

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #1146
Amount:
$888.15

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #475439
Amount:
$268.86

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1116
Amount:
$1,254.03

Component Description:
Project management services. #19-252
Amount:
$350.00

Component Description:
Legal Service Cost. #1001815
Amount:
$851.40

Component Description:
Project management services. #19-392
Amount:
$1,715.00

Component Description:
Legal services cost. #2020-WWLM
Amount:
$41.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 20 stations. #473857
Amount:
$1,198.13

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1118
Amount:
$1,609.03

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 18 stations. #472568
Amount:
$821.47

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #475011
Amount:
$1,023.40

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1112
Amount:
$521.40

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1104
Amount:
$644.80

Component Description:
Please refer to line 8 of the invoice for details
Amount:
$37.50

Component Description:
Project management services. #19-368
Amount:
$1,982.50

Component Description:
Legal services costs. #480865
Amount:
$75.00

Component Description:
Project management service. #19-289
Amount:
$287.50

Component Description:
Project management service. #19-201
Amount:
$562.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 20 stations. #1144
Amount:
$796.10

Component Description:
Project management services. #19-112
Amount:
$762.50

Component Description:
Project management service. #19-223
Amount:
$737.50

Component Description:
Project management service. #19-259
Amount:
$700.00

Component Description:
Project management service. #19-250
Amount:
$275.00

Component Description:
Legal services cost. #474779
Amount:
$24.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #472568
Amount:
$985.76

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 23 stations. #474243
Amount:
$1,304.02

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1096
Amount:
$714.93

Component Description:
Project management service. #19-155
Amount:
$962.00

Component Description:
Legal services cost. #475986
Amount:
$185.00

Component Description:
Project management service. #19-239
Amount:
$310.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 27 stations. #119
Amount:
$271.70

Component Description:
Project management services. #19-258
Amount:
$175.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Please see line 1 of the invoice - Prepare engineering section of FCC form 2100, construction permit application
Amount:
$2,250.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Consulting engineering services. #6545
Amount:
$123.75

Component Description:
Please refer to line 10 of the invoice for details
Amount:
$456.25

Component Description:
Please refer to line 9 of the invoice for details
Amount:
$783.19

Component Description:
Please refer to line 13 of the invoice for details
Amount:
$125.00

Component Description:
Consulting engineering services. #6564
Amount:
$454.50

Component Description:
Consulting engineering services. #6516
Amount:
$783.00
Internal Employee Time Costs

Component Description:
Internal time costs. #IL-HC2-10012021-RI
Amount:
$2,014.10

Component Description:
Internal time costs. #IL-HC2-09302021-PD
Amount:
$27.04

Component Description:
Internal time costs. #IL-HC2-08312020-AG
Amount:
$224.33

Component Description:
Internal time costs. #IL-HC2-09302020-RH
Amount:
$180.27

Component Description:
Internal time costs. #IL-HC2-08312020-IM
Amount:
$164.35

Component Description:
Internal time costs. #IL-HC2-08312020-DD
Amount:
$287.80

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $16,640.00 $7,877.50 N/A $1,777.77 N/A
Total for all systems $306,703.63 $107,451.63 N/A $58,368.15 N/A
Other Expenses $16,640.00 $7,877.50 $1,777.77
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $2,842.50 N/A $1,777.77 N/A
Equipment Storage $1,000.00 $1,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $1,000.00 $1,000.00 N/A N/A N/A
MVPD Notification of Channel Change $1,200.00 $1,200.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $250.00 $250.00 N/A N/A N/A

Components

Actual Information Description File Name
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
DTV Medical Facility Notification

Component Description:
Medical notification service. #INV-001873
Amount:
$1,777.77
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $306,703.63 $107,451.63 $58,368.15

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Michael Voge

Director of Engineering Operations


10/07/2021

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  5. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

  6. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

  8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Michael Voge

Director of Engineering Operations


10/07/2021

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